Failure to Address Pharmacist Medication Review Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure a prompt response to the registered pharmacist's monthly medication regimen review (MRR) recommendations for several residents, resulting in recommendations not being addressed in a timely manner. For one resident with severe cognitive impairment and diagnoses including dysphagia and dementia, the pharmacist repeatedly recommended evaluation and possible discontinuation of Nystatin-Triamcinolone cream and Acidophilus, as their continued use was not supported. Although the provider agreed with the recommendations, there was no documentation of timely follow-up or physician review, and the medications were not discontinued until much later than when the recommendations were signed. Another resident with severe cognitive impairment and multiple psychotropic medications did not have required Abnormal Involuntary Movement Scale (AIMS) assessments documented, and the facility was unable to produce MRR irregularity reports for review. Interviews revealed that the process for reviewing and implementing pharmacy recommendations had not been followed for at least two months, with reports not being reviewed or acted upon in a timely fashion. Additionally, medication consents were not on file for this resident prior to a certain date. A third resident with Alzheimer's disease and major depressive disorder had a pharmacist recommendation to evaluate the continued need for Vitamin B-12 and Lipitor due to terminal status, but there was no evidence that the physician or provider reviewed or responded to this recommendation. Interviews with facility staff confirmed a lack of awareness and follow-up regarding these recommendations. The facility's policy required that physicians document review and action on any pharmacist-identified irregularities by their next mandatory visit, but this process was not followed for the residents in question.